Darlow Marine Insurance P&I/H&M APP
Please complete as best you can and try not to leave any blank fields. If you are unsure how to answer a question try using "unknown" or "n/a" or "TBA" or "TBD"
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Shipowner: *
Individual or company name of the person/entity who owns the vessel
Address: *
Shipowner address
Phone #:
Telephone number
Fax #
Telephone number
E-mail:
E-mail address
Operator/Manager's name: *
Vessel operator company name. If the operators is same as owner, then state "same as owner"
Address: *
Operator's address
Phone #:
Telephone number
E-mail:
E-mail address
Years in Business
Years in business of either the owner or the operator (preferably whomever has more experience)
Vessel name: *
Vessel registration #
Country of Registry
IMO#: *
Call Sign
Year built: *
Construction
Where was vessel built
Hull Type
Single or Double hulled
Clear selection
Hull Material
Steel, Aluminum or Wood
Clear selection
Port of Registry
Flag: *
Classification society: *
If vessel is unclassed, enter "unclassed" in the box below
Length *
Breadth *
Draft *
Type of vessel: *
Barge, General, Ro-Ro, Tanker, Tug, etc..
Purchase Price
Date Purchased
Protection & Indemnity limit of liability:
P&I limit of liability requested in USD ($)
Hull & Machinery value:
Vessel hull value in USD ($)
If pollution coverage is needed, please provide limits required / requested.
If unknown, enter "same as P&I" or "as recommended" or "as required" below
Is a Certificate of Financial Responsibility (CoFR) needed?
* With a few limited exceptions, vessels greater than 300 gross tons and vessels of any size that are lightering or transshipping oil in the Exclusive Economic Zone (EEZ) are required to comply with the COFR regulations in order to operate in U.S. waters. The current (as of October 21, 2022) civil penalty amount per day for a COFR violation is $51,796.
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Is a Blue Card needed?
All ships over 1,000 GT registered in a State party or entering or leaving a port or terminal in the territory of a State party are required to have a Bunkers Convention Certificate "Blue Card" as part of the International Convention on Civil Liability for Bunker Oil Pollution 2001 (the “Bunker Convention”). Also required under the bunker convention is War Risk insurance on standard terms, with a separate limit for P&I liabilities up to the limit of the value of the ship. The required limit for P&I liabilities under that policy is the proper value of the ship, deemed not exceeding US$100 million.
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If Blue Card is needed, please provide the mailing address of the party state member port authority where the Blue Card needs to be sent to
Additional coverages
Crew (# of crew & nationality):
If coverage needed for crew, please include the # of crew members & their nationalities
Passengers (Max. # of passengers):
If coverage needed for passengers, please include the maximum # of passengers
GRT: *
Gross Registered Tonnage
Deadweight:
NRT:
Vessel Speed
Type of cargo carried: *
Navigation limits / Trading area: *
Make & quantity of Engine(s)
Engine(s) Model #
Model # for each Engine
Horse Power (total)
Type of Fuel: *
Fire extinguishers:
Clear selection
Name of present or last insurer:
5 Year loss history *
(Date of loss, Vessel name, Description of incident, Amount paid by company, if any? If no losses, please specify 'No losses')
Additional comments:
Signature of applicant: *
Title *
e.g. Vessel owner, operator, representative, President-CEO-Director of <Company Name>
Date of this submission *
MM
/
DD
/
YYYY
Email *
The quotation will be sent to this email.
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